Emerging Science in EMS

Transcription

1 Emerging Science in EMS Dane Wallace, NRP Assistant Professor of Paramedical Technology and EMS Program Coordinator University of Alaska Anchorage Matanuska Susitna College

2 Objectives: Learn basic skills to gather and review evidence based literature Practice critical thinking skills based on the analysis of research Evaluate how evidence based literature might become evidencebased practice in EMS

3 Evidence based, why? Data driven, evidence based EMS systems can promote improved quality of patient care. (NHTSA, 2017, n.p.)

4 National EMS Research Agenda With this document, we are seeking support for elevating the science of EMS and prehospital care to the next level. It is essential that we examine innovative ways to deliver prehospital care. Strategies to protect the safety of both the patient and the public safety worker must be devised and tested. There are many questions that remain to be asked, many practices to be evaluated, and many procedures to be improved. Research is the key to obtaining the answers. (NHTSA, 2001, p.4)

5 Disclaimer: This is a recruitment pitch: 1. Proposal: Statewide quarterly continuing medical education conference call based on EMS science based literature review. 2. Proposal: Annual statewide research summit where small workgroups develop Alaska specific research questions and access existing databases to gather data, develop and abstract on their findings and present the results (a poster ) during symposium.

6 Let s get down to it Research (or the lack thereof) we ll review today BLS versus ALS RLS Epinephrine (good or bad?) HUP CPR NTG in Inferior MI

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8 BLS vs ALS Ann Intern Med Nov 3;163(9): doi: /M Epub 2015 Oct 13. Outcomes of Basic Versus Advanced Life Support for Out of Hospital Medical Emergencies. Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Abstract BACKGROUND: Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. OBJECTIVE: To compare outcomes after ALS and BLS in out of hospital medical emergencies.

9 BLS vs ALS 1. What impact could this evidence have on EMS systems? 2. How might this data change the practice of EMS in Alaska? 3. What further questions does this research raise?

10 Red Lights and Siren(RLS) A review of the literature on emergency response reveals a consensus among authors that certain procedures, such as early defibrillation and application of CPR, correlate with improved survival. 1 However, today there doesn't appear to be a correlation between a response time standard of eight minutes and 59 seconds and improved survival. (Isaacs, 2017, n.p.)

11 RLS Personnel trained in an RLS protocol were 5.6 times less likely to transport RLS. Interestingly enough, although the group trained on RLS protocol transported far less (vs. a similar service that did not), there was no impact on patient outcome. (Merlin, 2012, p. 524) In a survey of more than 230,000 EMS personnel through the National Registry of EMTs, 7% reported having been in a crash, and 100% of these crashes were while using RLS. Surprisingly, weather was not a factor in any of these crashes. (Heick, 2009, p.963)

12 RLS 1. What impact could this evidence have on EMS systems? 2. How might this information change the practice of EMS in Alaska? 3. What further questions does this research raise?

13 Epinephrine During the third or "metabolic" phase of cardiac arrest, continuing dosages of EPI appear to be associated with a worse neurologic outcome in survivors. Continued accumulating dosages of EPI produce impaired oxygen utilization, increased myocardial oxygen demand, myocardial and cerebral ischemia, dysrhythmias, impaired lactate clearance, and a prothrombotic state. (Callaway, 2012, p. 1198)

14 Epinephrine In summary, the data suggest that the benefits of EPI are likely to be optimal in the first 10 minutes after cardiac arrest, and EPI may be detrimental beyond that timeframe. It's time to put the "backboard of cardiac arrest" aside. It's time to start making more intelligent decisions about how to care for victims of cardiac arrest and use EPI in a more sensible way instead of being strapped to dogmatic longstanding protocols that are bereft of good evidence.

15 Epinephrine In summary, the data suggest that the benefits of EPI are likely to be optimal in the first 10 minutes after cardiac arrest, and EPI may be detrimental beyond that timeframe. It's time to put the "backboard of cardiac arrest" aside. It's time to start making more intelligent decisions about how to care for victims of cardiac arrest and use EPI in a more sensible way instead of being strapped to dogmatic longstanding protocols that are bereft of good evidence.

16 Epinephrine Am J Emerg Med Sep;32(9): doi: /j.ajem Epub 2014 May 20. Epinephrine use and outcomes in anaphylaxis patients transported by emergency medical services. Manivannan V 1, Hyde RJ 1, Hankins DG 1, Bellolio MF 1, Fedko MG 1, Decker WW 1, Campbell RL 2. Author information Abstract BACKGROUND: Anaphylaxis is a potentially life threatening allergic reaction that may require emergency medical system (EMS) transport. Fatal anaphylaxis is associated with delayed epinephrine administration. Patient outcome data to assess appropriateness of EMS epinephrine administration are sparse. OBJECTIVES: The objectives of this study are to (1) determine the frequency of epinephrine administration in EMS transported patients with allergic complaints, (2) identify predictors of epinephrine administration, and (3) determine frequency of emergency department (ED) epinephrine administration after EMS transport.

17 Epinephrine Conclusion: Low rates of epinephrine administration were observed. The association of EMS administration of epinephrine with respiratory symptoms, fulfillment of anaphylaxis diagnostic criteria, and low rate of additional epinephrine administration in the ED suggest that ALS EMS administered epinephrine based on symptom severity. Additional studies of EMS anaphylaxis management including ED management and outcomes are needed.

18 Epinephrine In pediatric patients who met criteria for anaphylaxis and the use of epinephrine, only 54% received epinephrine and the overwhelming majority received it prior to EMS arrival. EMS personnel may not be treating anaphylaxis appropriately with epinephrine. (Carillo, 2015, n.p.)

19 Epinephrine 1. What impact could this evidence have on EMS systems? 2. How might this information change the practice of EMS in Alaska? 3. What further questions does this research raise?

20 HUP CPR Resuscitation May;102: doi: /j.resuscitation Epub 2016 Feb 22. The Effect of Head Up Cardiopulmonary Resuscitation on Cerebral and Systemic Hemodynamics. Ryu HH 1, Moore JC 2, Yannopoulos D 3, Lick M 4, McKnite S 5, Shin SD 6, Kim TY 7, Metzger A 8, Rees J 9, Tsangaris A 10, Debaty G 11, Lurie KG 12. Author information Abstract AIM: Chest compressions during cardiopulmonary resuscitation (CPR) increase arterial and venous pressures, delivering simultaneous bidirectional high pressure compression waves to the brain. We hypothesized that this may be detrimental and could be partially overcome by elevation of the head during CPR.

21 HUP CPR Conclusion: The HUP position in both C CPR and ACD+ITD CPR significantly improved CerPP. This simple maneuver has the potential to improve neurological outcomes after cardiac arrest.

22 HUP CPR 1. What impact could this evidence have on EMS systems? 2. How might this information change the practice of EMS in Alaska? 3. What further questions does this research raise?

23 NTG in Inferior AMI Prehosp Emerg Care. 2016;20(1): doi: / Epub 2015 May 29. Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction. Robichaud L, Ross D, Proulx MH, Légaré S, Vacon C, Xue X, Segal E. Abstract Patients with inferior SPrehosp Emerg Care. 2016;20(1): doi: / Epub 2015 May 29. Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction. Robichaud L, Ross D, Proulx MH, Légaré S, Vacon C, Xue X, Segal E. Abstract Patients with inferior ST elevation myocardial infarction (STEMI), associated with right ventricular infarction, are thought to be at higher risk of developing hypotension when administered nitroglycerin (NTG). T elevation myocardial infarction (STEMI), associated with right ventricular infarction, are thought to be at higher risk of developing hypotension when administered nitroglycerin (NTG).

24 NTG in Inferior AMI Conclusion: NTG administration to patients with chest pain and inferior STEMI on their computer interpreted electrocardiogram is not associated with a higher rate of hypotension compared to patients with STEMI in other territories. Computer interpretation of inferior STEMI cannot be used as the sole predictor for patients who may be at higher risk for hypotension following NTG administration.

25 NTG in Inferior AMI 1. What impact could this evidence have on EMS systems? 2. How might this information change the practice of EMS in Alaska? 3. What further questions does this research raise?

26 Thank You! Please if you are interested in either State wide Quarterly Literature Review CME or Annual EMS Research Summit.

27 Sources: National Highway Traffic Safety Administration (NHTSA). (n.d.). EMS Research. Retrieved April 1, 2017, from National Highway Traffic Safety Administration (NHTSA), & Maternal Child Health Bureau. (2001). National EMS Research Agenda. NATIONAL EMS RESEARCH AGENDA. Retrieved April 1, 2017, from Isaacs, M., MD, Cash, C., MD, Antar, O., MD, & Fowler, R., MD. (2017, February 1). The Case Against EMS Red Lights and Siren Responses. Retrieved April 1, 2017, from 42/issue 2/features/the case against ems red lights and siren responses.html Merlin MA, Baldino KT, Lehrfeld DP, et al. Use of a limited lights and siren protocol in the prehospital setting vs. standard usage. Am J Emerg Med. 2012;30(4):

28 Sources: Merlin MA, Baldino KT, Lehrfeld DP, et al. Use of a limited lights and siren protocol in the prehospital setting vs. standard usage. Am J Emerg Med. 2012;30(4): Callaway CW. Questioning the use of epinephrine to treat cardiac arrest. JAMA. 2012;307: Mattu, A., MD. (2015, October 30). Epinephrine: The 'Backboard' of Cardiac Arrest? Retrieved April 1, 2017, from Carrillo, E., Hern, H. G., & Barger, J. (2015, November 10). Prehospital Administration of Epinephrine in Pediatric Anaphylaxis. Retrieved from